SCHOLAR APPLICATION | 2015-2016 SCHOOL YEAR APPLICATION DEADLINE: WEDNESDAY, APRIL 1, 2015 Applications may also be submitted online at SuccessAcademies.org/Apply. While Success Academy schools offer Pre-K through 12th grade, we only accept applications for children entering Pre-K through 4th grade.† Your child must be four years old on or before December 31, 2015 to apply to Pre-K. Your child must be five years old on or before December 31, 2015 to apply to Kindergarten. STEP 1: CHILD INFORMATION EACH APPLYING CHILD REQUIRES A SEPARATE APPLICATION. Child’s First Name* Child’s Last Name* Home Address* Apt. Number City* Date of Birth* State* Month Day Zip* Borough Gender* Year Male Female Current School Name Not currently enrolled in school What grade is your child entering next school year (August 2015–June 2016)?* Kindergarten Pre-K • My child has difficulty with English because another language is spoken at home.◊ Yes No Yes No 1st Grade 2nd Grade 3rd Grade 4th Grade • My child’s current school has told me he/she is an English Language Learner (ELL).◊ ◊ † We are collecting this information because we give English Language Learners admission preference in the lottery. STEP 2: PARENT/GUARDIAN INFORMATION PARENT/GUARDIAN 1 PARENT/GUARDIAN 2 (IF APPLICABLE) Parent/Guardian Full Name* Parent/Guardian Full Name Relationship to Child* Relationship to Child Primary Phone* ( ) - Primary Phone ( ) - Secondary Phone ( ) - Secondary Phone ( ) - Work Phone ( ) - Work Phone ( ) - Email Email A SEPARATE APPLICATION MUST BE COMPLETED AND SUBMITTED FOR EACH CHILD APPLYING FOR ADMISSION. STEP 3: SIBLING INFORMATION Does your child have a sibling who is currently enrolled in a Success Academy Charter School?* If YES, please complete the following: Sibling’s First Name* Date of Birth* Month No Yes No Yes Sibling’s Last Name* Day Year Currently Enrolled Success Academy Gender Female Grade Entering Next Year* Does your child have a sibling who is applying to a Success Academy Charter School? If YES, please complete the following: Sibling’s First Name Male Sibling’s Last Name † Pending government approval *The items marked with an asterisk (*) are the only items that may be required in order to apply to this charter school. Any items not marked by an (*) are optional. CONTINUED ON BACK PAGE SCHOLAR APPLICATION | 2015-2016 SCHOOL YEAR Continued from front page STEP 4: CHOOSE SCHOOL(S)* IMPORTANT RANKING INFORMATION I am applying for my child to attend the following Success Academy (SA) school(s): (Check all that apply) If you are applying to more than one school, you may list your school preferences by ranking them to the right of the apply box. If you do not rank your schools, they will automatically be ranked by proximity to your home (closest to farthest). Your child will be entered in the lottery for ALL schools you've applied to, regardless of ranking. Ranking a school at the top or bottom of the list will not increase or decrease your chances of acceptance into that school. Ranking is used only to assign your child to your preferred Success Academy if he or she is accepted to more than one school. To rank your schools: PRE-KINDERGARTEN APPLY RANK SA Cobble Hill† SA Williamsburg† SA Harlem 1 † GRADES* ADDRESS Pre-K 284 Baltic Street Pre-K 183 South 3rd Street Pre-K 34 West 118th Street GRADES* ADDRESS ELEMENTARY APPLY RANK K,1,2,3,4 339 Morris Avenue SA Bronx 2 K,1,2,3,4 450 Saint Paul’s Place SA Bronx 3 K,1,2,3 968 Cauldwell Avenue SA Bronx 4 K,1,2 885 Bolton Avenue SA NYC 2 Bronx† (CSD9) K,1 TBD SA Bed-Stuy 1 K,1,2,3,4 70 Tompkins Avenue SA Bed-Stuy 2 K,1,2,3,4 211 Throop Avenue SA Cobble Hill K,1,2,3,4 284 Baltic Street SA Williamsburg K,1,2,3,4 183 South 3rd Street SA Fort Greene K,1,2,3 101 Park Avenue SA Crown Heights K,1,2,3 330 Crown Street SA Prospect Heights K,1,2,3 801 Park Place SA Bensonhurst K,1,2 99 Avenue P SA Bergen Beach K,1,2 1420 East 68th Street SA Harlem 1 K,1,2,3,4 34 West 118th Street SA Harlem 2 K,1,2,3,4 144 East 128th Street Date SA Harlem 3 SA Harlem 3 K,1,2 3,4 Mailing Address SA Harlem 4 K,1,2,3,4 240 West 113th Street SA Harlem 5 SA Harlem 5 K,1,2,3 4 Success Academy Charter Schools Attn: Enrollment 95 Pine Street, Floor 6 New York, NY 10005 Email [email protected] SA Upper West K,1,2,3,4 145 West 84th Street SA Hell’s Kitchen K,1,2,3 439 West 49th Street SA Union Square K,1,2,3 40 Irving Place K,1,2 701 Fort Washington Avenue SA Washington Heights * 410 East 100th Street 141 East 111th Street 301 West 140th Street 175 West 134th Street SA NYC1 Manhattan (CSD3) K,1 TBD SA Rosedale K,1,2 147-65 249th Street SA Springfield Gardens K,1,2 132-55 Ridgedale Street SA NYC3 Queens† (CSD 27) K,1 TBD † † 1) Assign a number to each selected school, where 1 is your most preferred school. 2) Every selected school must have a number. 3) Do not assign the same number to more than one school. 4) If accepted at more than one school, we will only reserve a seat for your child at the higher ranked school. SA Bronx 1 Pending government approval Grades that are currently accepting applications STEP 5: SIGN AND MAIL Admission is determined by a lottery. Admission is not limited based on any factor, but a lottery preference is given to: ■■ Siblings of current and accepted children ■■ English Language Learners (on-time applicants only)† ■■ Community School District (CSD) residents There is NO fee to apply to or attend a Success Academy. If you sign below, you are permitting Success Academy Charter Schools to use your child’s school records for data collection and analysis. No personal information is ever disclosed in these studies. Consenting to future studies, or not consenting, does not affect your child’s chances of being admitted. Sign Here TO LEARN MORE, GO TO www.SuccessAcademies.org/Apply * The items marked with an asterisk (*) are the only items that may be required in order to apply to this charter school. Any items not marked by an (*) are optional. Non-Discrimination Statement: A charter school shall not discriminate against or limit the admission of any student on any unlawful basis, including on the basis of ethnicity, national origin, gender, disability, intellectual ability, measures of achievement or aptitude, athletic ability, race, creed, religion or ancestry. A school may not require any action by a student or family (such as an admissions test, interview, essay, attendance at an information session, etc.) in order for an applicant to either receive or submit an application for admission to that school.